Engaging Clinicians to Reduce Care Variation Chris Wood MD Medical - PowerPoint PPT Presentation

Engaging Clinicians to Reduce Care Variation Chris Wood MD Medical Executive, Intermountain iCentra Development VP Cerner WelshConfed18

Intermountain Healthcare: Engaging Clinicians to Reduce Care Variation CHRIS WOOD, MD MEDICAL EXECUTIVE INTERMOUNTAIN DEVELOPMENT FEBRUARY 2018

Overview • Intermountain Healthcare has moved from a set of 15 independently run hospitals, to become one of the premier Health and Healthcare organizations in the United States with some of the best health outcomes at the lowest per capita price • How did this happen? • What principles learned here can be used in your work tomorrow?

Average Individual Insurance Premium 0 1000 2000 3000 4000 5000 Alaska Alaska RhodeIsland RhodeIsland Massachusetts Massachusetts Maine Maine NewHampshire NewHampshire Vermont Vermont Wisconsin Wisconsin Michigan Michigan NewJersey NewJersey Nevada Nevada Virginia Virginia Connecticut Connecticut NewYork NewYork Delaware Delaware Minnesota Minnesota Florida Florida Ohio Ohio Texas Texas SouthCarolina SouthCarolina Illinois Illinois Wyoming Wyoming Nebraska Nebraska Maryland Maryland Kansas Kansas Oregon Oregon WestVirginia WestVirginia Colorado Colorado Montana Montana Pennsylvania Pennsylvania Oklahoma Oklahoma Tennessee Tennessee Washington Washington Mississippi Mississippi Indiana Indiana Iowa Iowa Missouri Missouri NorthCarolina NorthCarolina Kentucky Kentucky California California Louisiana Louisiana SouthDakota SouthDakota Arizona Arizona Idaho Idaho Alabama Alabama NewMexico NewMexico NorthDakota NorthDakota Georgia Georgia Arkansas Arkansas Hawaii Hawaii Utah Utah 4 Source: Kaiser Family Foundation, 2006

Healthiness vs. Healthcare Cost per Capita

Beginnings to Integrated Health and Care System • Headquartered in Salt Lake City: 38,000+ employees • Created in 1975 when LDS Church donated its 15 hospitals to a Volunteer Community Board • Care for anyone who comes to you regardless of their ability to pay • Be a Model Clinic Organized EHR Disruptive Quality Innovations Data Improvement

Intermountain service area • 3 Million people • 28% covered by Select Health Insurance • 24 Hospitals 2,700 beds • 186 Clinics • 4,500 affiliated physicians • 1,500 employed physicians and APC • 37,000 employees 1,600 volunteers • 470 volunteer trustees

Transition in the Practice of Medicine • So much information! o US National Library of Medicine Added ~ 10,000 articles/week to online archives (40% of total) o 2005 > 14,000 RCT (1 st in 1952) o Medical knowledge doubles: o In 1950: every 50 years o In 2016: every 73 days • “Personal experience” can be misleading • Memory limited to 7 + 2

Practice of Medicine THE RESULT OF THE STATE OF THE ART IS WIDE VARIATION IN HOW WE PRACTICE AND THEREFORE IN THE OUTCOMES WE ACHIEVE

Transition in the Practice of Medicine • One physician, one patient – expert model o Care crafted by individual physician o Uses knowledge from training and experience • Changing – professional model o Working from “Shared baselines” o Iterative design and monitoring of care delivery o Demand that Physicians and Nurses step away from the baseline as needed by their individual patients

The Water We Swim In • Unintended Negative Consequences of our Business Model – The Bill you Better Game – Focus on provision of high margin procedures rather than on health of an individual patient – Necessity of Insurance • Federal • State • Private • Personal • With which Unintended Consequences are YOU dealing?

Reducing process variation improves processes, and thus improves outcomes categorically

The Intermountain Quality Model • Pareto approach – Focus on the “right” projects – Do enough, not too much – You can lose your way deciding on the “Right Way” • Right Team Clinicians, statisticians, informaticists, finance, simple project management administrative support • Develop a Shared Baseline of care (Care Process Model) – Goal is rapid deployment of a good, not the best, Shared Baseline – Avoid “Latest” and “Completeness” arguments – Realize you will begin with an Interpretation of Evidence, but transition to evaluation of your Data • Physician/Nurse Dignity – Demand them to deviate from the baseline as needed by their patient • Build organizational and team habits – Cue, Response, Reward – As much as possible, build it into the workflow: paper, EHR, other tools • Monitor the outcomes at an Individual, Team and Organizational level and adjust

Elements of success • Data Warehouse, Data Mart, Analysis capabilities to develop dashboards and meaningful reports – Are you Changing a Habit or Maintaining the New Habit? • Ability to build workflow process into EHR (Paper) • Ad Hoc Teams to own baselining Key Clinical Processes • Clinical Operations Leadership Team – Set Priorities – Monitor outcomes and maintenance • Align incentives

Key Clinical Processes • High volume process, affects a large number of patients • High Morbidity/Mortality, i.e. High Cost • Care is delivered by a definable clinical micro-system • Great variability in how care is delivered

Clinical Programs and Services Working Together SERVICES Behavioral Health Oncology Primary Care Musculoskeletal Surgical Services Intensive Medicine Pediatrics Cardiovascular Women & Newborns Neurosciences • Imaging • Pharmacy • Patient Flow • Rehabilitation • Nursing • Integrated Care Management • Laboratory • Respiratory • Pain Management • Patient and Provider Publications • Food and Nutrition Seamless Integration Across Clinical Programs • Patient Safety • Clinical Genetics

Clinical Program Structure Systemwide Guidance Council Medical Director Operations Director Data Manager Data Analyst Regional Management Team Regional Management Team Regional Management Team Operations Operations Medical Nursing Operations Medical Nursing Medical Nursing Officer Director Admin. Officer Director Admin. Officer Director Admin. Development Team Development Team Development Team

Health Pathways Health Pathway Recovery Preventative Diagnosis Management Treatment or Palliative Rehabilitative

Examples

From Hundreds of Success Examples, Three: • Newborn Resuscitation and Sepsis • Chest Pain management • Diabetes Prevention & Groceries

Women and Newborns’ Accomplishments and Successes 2014-2015 • Improved management of women in labor ▪ Our highest volume process • Standardization of Newborn Intensive Care Unit (NICU) processes ▪ An area of very high cost • Decrease in mom/baby length of stay • Decrease in newborns treated for risk of Early Onset Sepsis (EOS) • Initial deployment of teleservices for newborn care

iCentra Project Governance iCentra Executive Patient and Family Committee Advisory Council North Model System Affiliated Innovation Deployment Physician South Steering Committee Workgroup Committee Park City - Heber Population Emergency Ambulatory Acute Team CPOE Pharmacy Health Team Department Southwest Revenue Practice Patient Laboratory Imaging SelectHealth Primary Cycle Management Engagement Children’s Physician Executive Lead, CHIO, CNIO Central Clinical Programs Clinical Services Medical Director iCentra Advisors, Region CMIOs, Region CNIOs Pharmacy Clinical Operations Director Laboratory iCentra Physician Consultants and Advocates Guidance Council – Region Representation Imaging Development Teams – Region Therapies Physician Coaches and Super Users Representation Clinicians, Pharmacists, Care Managers, Clinic Managers, Operations, Finance

Link

Care Process Model Automation Paper-based Care Process Model Basic Flow Digitized Care Pathway Start Suggest appropriate CPMs - Select Monitor & Analyze Identify Show contextual views - Vital Signs, Lab, Allergies, etc Assess Tell me more - New data capture, decision flow Recommend Produce Recommendations - Order sets Action Interventions - Orders, Rx, Patient Education, etc. Document Complete Documentation - Physician impression, decision logo Measure

Workflow Driven Example

Continuum of Analytics Evidence Based Application Process Adoption Outcomes Practice Experience Did you follow Clinical Do you complete the right Do you use the system well Do you achieve the right Guidelines, Evidence,…any tasks on time, correctly and in and take advantage of health, financial, satisfaction Adverse events or Unnecessary the right sequence? preferences/techniques to outcomes? Variance improve efficiency? • Patient health Doctors not Un-reconciled meds Adverse events lead Example declines adopting Meds Rec lead to downstream to more labs, • Unreimbursed care because of poor negative imaging, • Patient and Family user experience consequences medications, labor, Upset LOS, procedures • Length of Stay vs Time to reconcile % Meds Administered Adverse Events Baseline meds w/un-reconciled meds • Unreimbursed Care Metrics Redundant Labs (Never List) • Meds Rec Adoption Adverse events Patient Satisfaction Unnecessary • % from un-reconciled Patient Functional Imaging meds Status